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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608084
Report Date: 05/05/2023
Date Signed: 05/05/2023 04:57:34 PM

Document Has Been Signed on 05/05/2023 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:OUR SWEET HOME INC #3FACILITY NUMBER:
197608084
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:21054 VINTAGE STTELEPHONE:
(818) 960-5224
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 5DATE:
05/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Tina Arutyunyan, Administrator TIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management - Incident visit. LPA met with Administrator and explained the reason for the visit.

On 05/04/23, the Department received a self-reported incident report stating that Resident #1 (R1) had left the facility on 05/03/23 and did not return. The incident was reported to police.

During today's visit, LPA conducted a physical plant walk through, at approximately 9:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

LPA conducted interview with the Administrator and two (2) staff members. LPA also obtained copies of R1's facility records.

Upon review of the physician's report dated 02/15/2023, the report states that R1 has dementia and is not able to leave the facility unassisted. Interview with the Administrator and two (2) staff members revealed that R1 lived at the above facility for almost three (3) years and was very happy with the place. All staff denied seeing changes in R1's behavior. Interview with S1 revealed that on a day of an incident, at approximately 6:30pm, R1 asked S1 to change the TV channel. S1 also informed LPA that around 7:00pm S1 checked on R1 again and observed R1 exercising. When S1 checked on R1 around 7:15pm, S1 observed R1 left the facility through the window and staff lost track of R1. S1 immediately contacted the Administrator and the law enforcement regarding the incident. R1 is still missing and Administrator currently does not have any updated information on R1's whereabouts. LPA will conduct a follow up visit regarding this incident.

Exit interview conducted and copy of this report signed and issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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